Assessment of therapeutic compliance and its associated factors in tunisian adult asthmatic patients.

INTRODUCTION: Despite therapeutic advances, morbidity attributed to asthma continues to increase. This seems partly to be due to poor adherence. AIM: To assess therapeutic adherence and the association between poor compliance and asthma control. METHODS: We carried out a descriptive cross-sectional study on a sample of 150 asthmatics, followed in the pneumology department of Charles Nicolle hospital for more than 6 months. The survey took place over 1 month. The 4-item Morisky questionnaire (MMAS-4) was used to assess adherence to therapy. RESULTS: Our patients had a median age of 44.2 years and a sex ratio of 0.47. Asthma was severe in 48% of cases and poorly controlled in 34% of cases. Adherence was poor in 66% of patients. Factors significantly associated with adherence were educationlevel (p=0.02), socio- economic status (p = 0.01), treatment cost (p= 0.02), its availability (p=0.04) and its free cost (p = 0.001), consultation waiting time (p=0.03) and knowledge on asthma (p=0,04). We retained in multivariate analyze two factors determining therapeutic adherence, which are socio-economic status (OR = 2.02 ; [1.2-6.26]) and participation in the therapeutic choice (OR = 1.2 ; 95% CI [2.02-4.25]). CONCLUSIONS: It appears that medication adherence is widely influenced by socio-economic status. So, improving these conditions would guarantee better treatment compliance.

Macrolides for better resolution of community-acquired pneumonia: A global meta-analysis of clinical outcomes with focus on microbial aetiology.

OBJECTIVES: This meta-analysis examined the effect of macrolides on resolution of community-acquired pneumonia (CAP) and interpretation of clinical benefit according to microbiology; emphasis is given to data under-reported countries (URCs). METHODS: This meta-analysis included 47 publications published between 1994 and 2022. Publications were analysed for 30-d mortality (58 759 patients) and resolution of CAP (6465 patients). A separate meta-analysis was done for the prevalence of respiratory pathogens in URCs. RESULTS: Mortality after 30 d was reduced by the addition of macrolides (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.51-0.82). The OR for CAP resolution when macrolides were added to the treatment regimen was 1.23 (95% CI 1.00-1.52). In the CAP resolution analysis, the most prevalent pathogen was Streptococcus pneumoniae (12.68%; 95% CI 9.36-16.95%). Analysis of the pathogen epidemiology from the URCs included 12 publications. The most prevalent pathogens were S. pneumoniae (24.91%) and Klebsiella pneumoniae (12.90%). CONCLUSION: The addition of macrolides to the treatment regimen led to 35% relative decrease of 30-d mortality and to 23% relative increase in resolution of CAP.

Misdiagnosis asthma in adult, three rare causes.

INTRODUCTION: All that wheezes is not asthma. Although, asthma is the most common cause of wheeze and cough in children and adults, it is often attributed inappropriately to these symptoms from other causes. AIM: We illustrate through this manuscript three rare causes of wheeze in adults, misdiagnosis as asthma. OBSERVATIONS: The three reported cases were misdiagnosed as difficult-to-treat asthma. They were found as mimicking asthma. Final diagnoses were localized tracheobronchial amyloidosis, aortic arch anomalies, and idiopathic chronic eosinophilic pneumonia. CONCLUSION: Although asthma is a common cause of various respiratory symptoms, all that coughs and wheezes is not asthma. So before retaining the severe asthma diagnosis, we have to exclude various differential diagnoses, even the rarest ones. Several diagnostic tests have to be done to have the appropriate diagnosis.

Structured observation summaries : educational interest in the teaching of pulmonology.

BACKGROUND: The structured observation summary (SOS) is a method of active case-based learning, whose diagnosis is known to learners. AIM: To assess the value of SOS in the learning of clinical reasoning in pulmonology among first year students of the second cycle of medical studies. METHODS: This was a descriptive cross-sectional study. Teaching was provided to 3 groups of students in three sessions per group in the staff room of the pneumology department of Charles Nicolle Hospital in Tunis, during the second semester of the 2019/2020 academic year. We compared the scores assigned to a given test before and at the end of the session to assess knowledge acquisition. The students filled out a satisfaction questionnaire at the end of the session. RESULTS: We held 9 tutorial sessions in which 30 learners participated and 78 SOSs were completed. The subjects chosen were respectively tuberculosis, pneumothorax, and fluid pleurisy. After correcting the SOS cards, we saw an improvement in averages and scores during the sessions. Learners found no difficulty in completing the items relating to historical data and physical examination. The section relating to «particularities to report¼ was not completed throughout the sessions. By comparing the scores assigned to the test before and at the end of the session, a statistically significant improvement was noted for the 3 themes with p=0.003, p=0.001, p=0.002, respectively. The response to the satisfaction questionnaire revealed that most students were satisfied with the general learning process (95%). They judged the content of the sessions to be relevant (95%) and felt that this teaching facilitated the process of their clinical reasoning (97%). CONCLUSIONS: The satisfaction recorded by the students regarding this project invites us to extend its scope. However, some changes need to be made to the SOS form.

Comparative study of six SARS-CoV-2 serology assays: Diagnostic performance and antibody dynamics in a cohort of hospitalized patients for moderate to critical COVID-19.

BACKGROUND: To overcome the COVID-19 pandemic, serology assays are needed to identify past and ongoing infections. In this context, we evaluated the diagnostic performance of 6 immunoassays on samples from hospitalized patients for moderate to critical COVID-19. METHODS: 701 serum samples obtained from 443 COVID-19 patients (G1: 356 positive RT-PCR patients and G2: 87 negative RT-PCR cases) and 108 pre-pandemic sera from blood donors were tested with 6 commercial immunoassays: (1) Elecsys Anti-SARS-CoV-2, Roche (Nucleocapsid, N), (2) Elecsys Anti-SARS-CoV-2 S, Roche (Spike, S), (3) Vidas SARS-COV-2 IgM/IgG, BioMérieux (S), (4) SARS-CoV-2 IgG, Abbott (N), (5) Access SARS-CoV-2 IgG, Beckman Coulter (Receptor Binding Domain), and (6) Standard F COVID-19 IgM/IgG Combo FIA, SD Biosensor (N). RESULTS: Global sensitivities of the evaluated assays were as follows: (1) Roche anti-N = 74.5% [69.6-79.3], (2) Roche anti-S = 92.7% [84.7-100], (3) Vidas IgM = 74.9% [68.6-81.2], (4) Vidas IgG = 73.9% [67.6-80.1], (5) Abbott = 78.6% [63.4-93.8], (6) Beckman Coulter = 74.5% [62-86.9], (7) SD Biosensor IgM = 73.1% [61-85.1], and (8) SD Biosensor IgG = 76.9% [65.4-88.4]. Sensitivities increased gradually from week 1 to week 3 as follow: (1) Roche anti-N: 63.3%, 81% and 82.1%; (2) Vidas IgM: 68.2%, 83.2% and 85.9%; and (3) Vidas IgG: 66.7%, 79.1% and 86.6%. All immunoassays showed a specificity of 100%. Seropositivity was significantly associated with a higher frequency of critical COVID-19 (50.8% vs. 38.2%), p = 0.018, OR [95% CI] = 1.668 [1.09-2.553]. Inversely, death occurred more frequently in seronegative patients (28.7% vs. 13.6%), p=3.02 E-4, OR [95% CI] = 0.392 [0.233-0.658]. CONCLUSION: Evaluated serology assays exhibited good sensitivities and excellent specificities. Sensitivities increased gradually after symptoms onset. Even if seropositivity is more frequent in patients with critical COVID-19, it may predict a recovery outcome.

Oscillococcinum® for upper respiratory tract infections and exacerbations in COPD: an observational, prospective study (OXITUNIS).

BACKGROUND: Upper respiratory tract infections (URTIs) are a major cause of exacerbations in patients with chronic obstructive pulmonary disease (COPD). We assessed the effectiveness of Oscillococcinum® in the protection from URTIs in patients with COPD who had been vaccinated against influenza infection over the 2018-2019 winter season. METHODS: Patients (n=106; mean ± standard deviation age: 66.0 ± 10.3 years; 89.6% men) were randomized into two groups: group V received influenza vaccination only and group OV received influenza vaccination plus Oscillococcinum® (one oral dose per week from inclusion in the study until the end of follow-up, with a maximum of 6 months follow-up over the winter season). The primary endpoint was the incidence rate of URTIs (number of URTIs/1000 patient-treatment exposure days) during follow-up compared between the two groups. RESULTS: There was no significant difference in any of the demographic characteristics, baseline COPD, or clinical data between the two treatment groups (OV and V). The URTI incidence rate was significantly higher in group V than in group OV (2.9 versus 1.2 episodes/1000 treatment days, difference OV-V = -1.7; p=0.0312). There was a significant delay in occurrence of an URTI episode in the OV group versus the V group (mean ± standard error: 48.7 ± 3.0 versus 67.0 ± 2.8 days, respectively; p=0.0158). Limitations to this study include its small population size and the self-recording by patients of the number and duration of URTIs and exacerbations. CONCLUSION: Oscillococcinum may decrease the incidence rate and delay the appearance of URTIs in patients with COPD.

Asthma in Menopausal Women: Clinical and Functional Particularities.

BACKGROUND: Hormonal changes in women, especially at menopausal transition, may have significant consequences on respiratory function. This issue in asthmatic patients is more frequent, more severe, and less controlled after menopause. Tunisian data regarding this issue are limited; therefore, we assessed the clinical and functional particularities of asthma at menopausal transition. MATERIALS AND METHODS: This descriptive-analytical study was performed for two years (2016-2017) on 82 asthmatic women followed up in the pulmonology department of Charles Nicolle hospital of Tunis. According to hormonal status, two groups were defined: G1 (menopausal patients) and G2 (non-menopausal patients). Asthma control and severity of asthma as well as other variables including gender, age, body mass index (BMI), comorbidities, allergenic status, spirometry results, health care use in the past 12 months, and prescribed medications were evaluated. RESULTS: The mean age of patients was 50 years and half of them (60%) were menopausal women. Allergy was the most common cause of asthma (82%). A mean of 2.3 exacerbations per patient was recorded. Asthma was well controlled in 58% of patients and was moderate to severe in 80% of them. Menopausal asthmatic women had more comorbidities (p=0.006), particularly arterial hypertension (p<0.0001). Atopy was more common in non-menopausal women and they were all allergic (p=0.01). Menopausal asthmatic patients had more airflow obstruction with lower forced expiratory volume 1 and forced vital capacity (p<0.0001). They also had more exacerbations (p<0.0001) with lower PaO2 (p=0.006). Univariate analysis showed that menopause was a predictive factor of severity (p=0.01) and bad control of asthma (p=0.03). Multivariate analysis confirmed that menopause was a predictor of severity (p=0.01; OR=5.02, IC [1.36-18.46]) but not control of asthma despite the tendency to significance (p=0.07). CONCLUSION: Our results confirm that menopause is a factor influencing the control and severity of asthma.

Tracheobronchopathia Osteochondroplastica: End Stage of Tracheo-Bronchial Amyloidosis?

Tracheobronchopathia osteochondroplastica is a rare idiopathic disease of the trachea and the main bronchi, characterized by multiple submucosal osteocartilaginous nodules. Although the etiology of tracheobronchopathia osteochondroplastica remains unknown, several theories have been proposed. We report a case of a 47-year-old non-smoker woman with wheezing dyspnea over the past two years, which was treated as asthma without improvement. Investigations, including chest computed tomography scan, fiberoptic bronchoscopy, and endobronchial biopsy, indicated tracheobronchial amyloid light-chain (AL) amyloidosis. Thirteen years later, she was admitted for cough and wheezing. The bronchoscopic examination demonstrated nodular lesions distributed along the cartilaginous rings of the lower portion of the trachea and the main bronchi. Endobronchial biopsy confirmed tracheobronchopathia osteochondroplastica. We found tracheobronchopathia osteochondroplastica to be the end stage of amyloidosis.

Impact of smoking on the severity of Obstructive Sleep Apnea Hypopnea Syndrome.

BACKGROUND: Smoking is an established risk factor of several respiratory and extra respiratory diseases. However, the effect of smoking on obstructive sleep apnea syndrome (OSAS) is not well characterized. The purpose of this work is to study the influence of smoking on the severity of OSAS. METHODS: We performed a retrospective study, which included patients with an obstructive sleep apnea syndrome diagnosed in the pulmonology department of Charles Nicolle Hospital in Tunis, during the period from January 2008 to December 2014. RESULTS: We collected 104 patients with obstructive sleep apnea syndrome. The average age of patients was 49,4 years (14-81 years). The majority of patients were women (53,8%). Thirty two patients were smokers with an average consumption of 27 PA. The reasons for consultation were nocturnal snoring (90%), daytime sleepiness (77%), respiratory pauses (53%), nocturia (35%), daytime fatigue (34%) and headache (29% ). The average weight was 92 kg. The average BMI was 33 kg / m2. The average waist circumference was 98 cm. On average, the Epworth score was 12. The apnea hypopnea index was on average 32 / h. A slight OSAS was noted in 28,8% of cases, moderate OSAS in 14,4% of cases and severe OSAS in 53,8% of cases. The number of desaturations averaged 155. The CPAP treatment was fixed in 61 patients (58%) and self-controlled in 5 patients (4,8%). Adherence was checked in 48 patients (46%) and it was good in 85% of cases. The comparison between the smoking and non-smoking subjects was about; the Epworth scale, FEV, AHI, mean SpO2 and observance of treatment but no significant difference was found. CONCLUSION: Although our study did not find any difference between smokers and non smokers, smoking cessation takes an important place for management of a patient with OSAS.

ALK protein expression in pulmonary adenocarcinoma of Tunisian patients.

BACKGROUND: It is now necessary to determine ALK status in order to use targeted therapy. AIM: herein, we assess immunohistochemical profile of ALK protein in a series of Tunisian patients with pulmonary adenocarcinoma. MATERIALS AND METHODS: ALK protein expression was studied applying the D5F3 antibody with a fully automated Ventana CDx technique on a series of 19 patients. RESULTS: Positive ALK expression was found in one case (5.2%) corresponding to a papillary adenocarcinoma which showed a strong granular and homogenous cytoplasmic staining. The patient was a 30-years-old woman. CONCLUSION: The frequency of positive ALK expression based on immunohistochemistry in our series was similar to that reported in the world literature.

Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis.

Chylothorax is a rare manifestation of tuberculosis. We report a case of spontaneous chylothorax due to tuberculosis. A 62-year-old woman was admitted with fever, chest pain and dyspnea. Chest and abdominal computed tomography revealed a fluid collection with necrotic mediastinal and abdominal lymph nodes. Biopsy of lymph nodes by mediastinoscopy. The patient was treated with anti-tuberculosis medication. He is clinically improved and his pleural effusion also completely resolved.

Role of procalcitonin and c-reactive protein levels: a diagnostic tool in lower respiratory tract infections.

BACKGROUND: Conventional biomarkers lack sensitivity and specificity for acute pulmonary Community (PAC). Procalcitonin (PCT) has been described in the literature for its usefulness in the PAC. The aim of our work was to study the contribution of the PCT in the positive diagnosis of PAC and in the initial assessment of the severity and the interest of CRP and PCT to distinguish lung infections from tuberculous origin of the PAC. METHODS: Prospective study of 100 middle-aged 45 years [16-82], admitted to our clinic for evaluation of lung opacity some of the reason for consultation. All patients with antibiotics before admission were excluded. We studied the clinical, radiological, biological and bacteriological characteristics of patients. RESULTS: The rate of PCT was significantly higher in PAC compared to TBC (p <0.001). The values of CRP and PCT were correlated to changes in the PAC. The mean values of CRP and PCT were higher for the most severe PAC and the difference was statistically significant for CRP and PCT between the two (p =0.01). The cut-off of CRP and PCT could discriminate a PAC values were 35 mg / l and 0.12 ng /ml. CONCLUSION: The PCT is a good marker for diagnosis and the prognosis of PAC. It permits  to discriminate diagnosing CAP compared to tuberculosis.

[Predictive factors of the outcome of smoking cessation among Tunisian women]. / Facteurs prédictifs des résultats du sevrage tabagique chez la femme tunisienne.

BACKGROUND: The spread of smoking among women in Tunisia has reached alarming proportions because of increasing smoker rate, the younger age of smoking initiation and therefore its duration. AIM: Identify predictors of success or failure of smoking cessation, Methods: we conducted a retrospective study (January 2008-June 2011), including 101 female smokers (19.8%) among 510 smokers of both sexes undergoing smoking cessation interventions. Univariate and multivariate analysis between groups of smokers who succeeded and who failed smoking cessation was performed. RESULTS: Average age of our patients was 44 years. The overall success rate at 6 months and 1 year were respectively 24.7 and 18.8%. In univariate analysis, a statistically significant difference in terms of successful weaning was observed in smokers who had a late age of smoking onset (after 20 years) (p=0.03), respiratory or cardiovascular comorbidities associated (p=0.03) and good adhesion to the consultation (p=0.02). In multivariate analysis only the presence of a tobacco-related disease (OR: 4.43, 95% CI [1.29- 15.17], p=0.01) and adherence to the consultation (OR 5.02 95% CI [1.29 -19.39], p=0.01) were significantly associated with a good prognosis for successful weaning at 6 months and one year. A possible but not significantly associated with age of smoking initiation was observed (OR=0.3 95% CI [0.08-1.07], p=0.06). CONCLUSION: Beyond validated smoking cessation and prolonged follow-up, a differential approach, taking into account women specificities, would increase the chances of quitting smoking.